Risultati per: Libro sugli antibiotici del WHO AWaRe (Access, Watch, Reserve)

Objective
This qualitative study aimed to analyse rectal cancer survivors’ lived experiences to identify facilitators and barriers to support access.

Design
We conducted one-on-one semi-structured interviews and employed thematic analysis to identify key themes and insights.

Setting/participants
Participants included eight rectal cancer survivors and three caregivers recruited at Texas Colorectal Collaborative sites.

Results
Results showed that adequate hospital resources, high health literacy and close connections with clinicians and peers who share similar experiences facilitate survivors’ access to social support. Conversely, ineffective healthcare team communication, financial challenges and low self-motivation hindered access.

Conclusion
Survivorship experiences were shaped by varying degrees of social support access, influenced by internal and external factors. We aim to establish a cross-institutional survivorship support network to address these factors, ensuring equitable access to support services and enhancing survivorship experiences.

Schillaci: La resistenza è un’emergenza globale. No al fai da te’

UniCamillus, oggi 99,6% dei piccoli trattato nel modo sbagliato

The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to facilitate understanding and improve the clinical practice of endoscopic enteral access.

Introduction
In 2021, among French women who smoked when they knew they were pregnant, 59% still smoked at the end of pregnancy. Support for pregnant women to stop smoking must include a structured organisational perspective. The main objective of the study is to evaluate the effectiveness of the 5A-QUIT-N organisational intervention on smoking cessation at delivery among pregnant women who smoke during pregnancy.

Methods and analysis
The overarching goal of the 5A-QUIT-N intervention, which aims to organise the healthcare professionals monitoring pregnancy, specialists in addiction and tobacco use, and clinical and training tools, using the 5As method. The 5A-QUIT-N intervention will be evaluated in a pragmatic stepped-wedge cluster randomised trial. Within each cluster, during the 6 months before (control) and after (intervention) the intervention, women who smoke tobacco during pregnancy will be enrolled during their maternity stay after delivery. A transition period is planned between the control and intervention periods to deploy the intervention. All participating women will be interviewed using a heteroquestionnaire to assess smoking cessation, tobacco use monitoring by healthcare professionals and individual factors associated with tobacco use during pregnancy. The primary outcome was the point prevalence of abstinence at delivery, which is the proportion of women reporting abstinence from smoking for at least 7 days at delivery. 4200 women who smoked tobacco during pregnancy will be recruited over the entire study period (33 months) to evaluate the effectiveness. An estimated 4585 participants will be included for all aims.

Ethics and dissemination
The study will be implemented in accordance with French regulations. The study including the consent process has been independently reviewed and approved by the French ethical board ‘CPP Ile de France I’ on 10 February 2022 (No CPPIDF1-2022-DI08-cat.2). The results will be disseminated on various academic and non-academic platforms. The results will be reported in international peer-reviewed journals and presented at international and national conferences.

‘Necessaria la sorveglianza delle infezioni nelle strutture sanitarie’

Circulation, Volume 150, Issue Suppl_1, Page A4141469-A4141469, November 12, 2024. Background:Dyspnea on exertion is cardinal symptom in heart failure (HF) and may be caused by an unfavorable dynamic of ventricular interaction. This concept has been poorly addressed over time and we hypothesized that a careful study of the interventricular septum adaptations during maximal exercise in HF might be implicated in the limited cardiac reserve and uncoupling of right ventricular (RV) to pulmonary circulation (Pc), both yielding to a limited O2 uptake.Aim:To study the pathophysiology behind biventricular interaction during exercise in HF, evaluating the role of septum displacement during exercise and how and whether it would affect peak exercise oxygen consumption (VO2peak) through a limited cardiac output (CO) increase and some degrees of RV to PC uncoupling assessed by TAPSE/PASP.Methods:22 HF performed a combined cardiopulmonary exercise testing imaging (CPET imaging) with RV 3D-imaging analysis and were compared with a control population.3D imaging of the RV chamber was examined off-line using the 4D RV TomTec software and obtained 3D mesh of the RV model using custom software to obtain the mean curvature value of IVS in 4 regions of: inflow tract (RVIT), outflow tract (RVOT), apical and body. We acquired measurements of curvature during end-diastole (ED) and at end systole (ES) phases and obtained a parametric curvature map.Results:HF patients (mean age 72±12, 27% female) typically showed an abnormal septal curve, with a more leftward configuration either at rest and under exercise (rest =−0.01±0.007 at ED, and −0.01±0.009 at ES; peak exercise= −0.01±0.006 at ED, and −0.01±0.007 at ES) compared to controls (rest=−0.02±0.002 at ED, and −0.02±0.006 at ES; peak exercise −0.02±0.0.006 at ED, and −0.02±0.01 at ES, Figure). Notably, the degree of the IVS curvature showed a linear correlation with an impaired gas exchange performance as indicated by a lower peak VO2, a limited CO and impairment of TAPSE/PASP in HF (respectively, r=0.64, p

Circulation, Volume 150, Issue Suppl_1, Page A4123637-A4123637, November 12, 2024. Background:Invasive coronary reactivity testing (CRT) is the gold standard for comprehensive assessment of coronary endothelial and microvascular dysfunction in patients with angina and non-obstructive CAD (ANOCA). Non-invasive imaging modalities (PET and CMR) have emerged as potential alternatives. However, due to the inability to systemically administer acetylcholine, patients with normal coronary flow reserve (CFR) but abnormal endothelial function on invasive Ach testing are systemically missed on non-invasive testing. We aimed to assess the prevalence of coronary endothelial dysfunction in ANOCA patients with normal CFR.Methods:Consecutive patients undergoing CRT at our institution were included. Those with normal adenosine-based CFR ( >2.5), were further stratified as having normal coronary endothelial function (NEF, 50% increase in coronary blood flow in response to ACh) vs abnormal endothelial function (AEF, >20% epicardial coronary diameter constriction and/or

Circulation, Volume 150, Issue Suppl_1, Page A4140154-A4140154, November 12, 2024. Introduction/Research Question:Allosensitization, the presence of circulating anti-HLA antibodies, is a barrier in heart transplantation (HT), restricting the donor pool size, and leading to increased waitlist mortality and rejection risk post-HT. Desensitization therapies can be used to broaden the donor pool in highly sensitized patients, defined as pre-HT calculated panel reactive antibodies (cPRA)≥50%, for antibodies with mean fluorescence intensity (MFI) >10,000. There is paucity of data on longer-term outcomes in such high-immunological risk patients.Methods:Sensitized patients with pre-HT cPRA >50%, who were treated with desensitization and then received HT between 2011-2022 at Cedars-Sinai Medical Center were included. Desensitization therapies included bortezomib, rituximab, tocilizumab, obinutuzumab, intravenous immunoglobulin (IVIG), and plasmapheresis. cPRA, donor-specific antibody (DSA) levels, and post-HT clinical outcomes were assessed up to 5-year follow-up, loss to follow-up, or death.Results:40 patients were analyzed. 77.5% of patients were female, and all had at least 1 risk factor for sensitization. cPRA decreased from 84.5±13.5% at baseline to 74.1±22.4% after completion of desensitization therapy, prior to transplant (p=0.005). Mean follow-up time post-HT was 4.3±2.9 years. 45.0% of patients had antibody-mediated rejection (AMR), 12.5% had CAV. Overall survival was 94.9%, 92.1%, and 87.5% at 1, 3, and 5 years respectively. All patients except 1 had normal left ventricular function at last follow-up. 72.5% of patients were transplanted in the presence of DSA, and 60.0% underwent post-HT induction with eculizumab in addition to antithymocyte globulin (ATG)/IVIG, while the remaining received ATG/IVIG alone. Among HT recipients with pre-formed DSA, 41.4% had high-level DSA (MFI > 10,000) at time of HT. At 6-12 months post-HT, only 17.2% had high-level DSA, and 41.4% had resolution of DSA.Conclusion:Highly sensitized HT candidates who underwent pre-HT desensitization had comparable survival and CAV rates as compared to the general HT population reported in the literature. However, sensitized patients experienced higher rates of AMR which were not associated with graft dysfunction or mortality.

Circulation, Volume 150, Issue Suppl_1, Page A4142395-A4142395, November 12, 2024. Background:Hybrid cardiac rehabilitation (HCR) is an emerging approach to increase participation in cardiac rehabilitation, which targets improvements in functional status and broader risk factor modification including lipid management. However, long-term lipid control trends of patients engaging in HCR remain unexplored.Methods:Using data from a quality improvement program initiated during COVID-19, we conducted a retrospective analysis of 68 adults eligible for HCR from Jan 2021 to Feb 2023 at the Johns Hopkins Health System (Baltimore, MD), utilizing the Corrie digital health platform. This multi-component platform combines expert knowledge with gamified education and virtual coaching to deliver HCR. Patients hospitalized for cardiovascular events qualifying for HCR were recruited for a pilot study of a randomized controlled trial (mTECH REHAB; NCT05238103). We modeled trends in low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides via mixed-effects regression.Results:Among 68 eligible adults, 41 participated in HCR, with a mean age of 60.1 years, 78.1% male, 24.3% Black, and 14.6% Asian/Mixed. HCR participation was significantly associated with being married (61% vs 33%, p=0.044) or employed (63% vs 26%, p=0.015). On average, 2.3 lipid panels were assessed per person over a median of 12 months (max 30 months) post-discharge. During this period, LDL-C levels decreased from 84.6 mg/dL (95% CI: 75.0-94.1) to 53.0 mg/dL (95% CI: 34.3-71.8) (p for trend = 0.003). Non-HDL-C decreased from 105.9 mg/dL (95% CI: 95.7-116.1) to 74.2 mg/dL (95% CI: 54.1-94.3) (p for trend = 0.005). Levels of HDL-C and triglycerides showed no significant changes (p for trend = 0.724 and 0.607). Among 34 participants with ≥2 lipid panels, the proportion of LDL-C

Circulation, Volume 150, Issue Suppl_1, Page A4141392-A4141392, November 12, 2024. Introduction:Inclisiran is a novel small interfering RNA indicated to reduce LDL-C as an adjunct to diet and statin therapy for the treatment of adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH). It is administered subcutaneously initially, again at 3 months, and then every six months by an HCP. Subsequent doses may be administered within three months after the scheduled dose without restarting a new dose schedule. Few studies have investigated out of pocket (OOP) costs for patients receiving inclisiran. Metro Infusion Center (MIC) is one of the largest infusion centers across the US with over 200 centers in 38 states.Objective:To describe the real-world changes in LDL-C levels and OOP costs associated with inclisiran use at MICs.Methods:Patient charts for those who initiated inclisiran between March 1, 2022 and November 30, 2022 and who received ≥2 doses were reviewed retrospectively. Patient characteristics at initiation were collected and patients were followed until February 2024. Study outcomes included changes in LDL-C levels from baseline and OOP cost by payer type. The incidence of adverse events (AEs) was extracted from the chart if documented.Results:A total of 534 patients who initiated inclisiran received ≥2 doses. Mean (SD) age was 70.2 (10.3) years and 50% were male. The majority of patients (81%) were covered by Medicare. A total of 479 (90%) patients had a history of ASCVD and 55 (10%) had HeFH. Prior PCSK9i use was reported in 35% of patients, and 54% had concurrent statin therapy. Among 274 patients with LDL-C measurements, mean (SD) baseline LDL-C was 147.2 (59.7) mg/dL. After initiating inclisiran, the average reduction in LDL-C from baseline was 47%. The average OOP costs for the initial dose was $37 ($0-$2950) for Medicare insured patients and $115 ($0-$1300) for patients covered by commercial insurance. Among patients insured by Medicare, 96% paid $0 OOP for both doses. A total of 24 (4%) patients reported an AE, and half discontinued treatment. The most commonly reported AEs were muscle weakness and joint pain in 5 patients.Conclusion:These real-world data demonstrate significant LDL-C reductions within 1 year in patients who initiated inclisiran, which is consistent with the ORION clinical development program. Most patients were covered by Medicare, nearly all of whom had $0 for OOP costs compared with average costs of $115 for initial dose for commercially insured patients.

Circulation, Volume 150, Issue Suppl_1, Page A4142743-A4142743, November 12, 2024. Backgrounds:Chronic venous insufficiency (CVI) is a condition of the venous wall and/or valves’ dysfunction in the leg veins prone to venous thrombosis and reducing quality of life. This study sought to find risk factors of CVI and develop a dedicated risk score model to predict the presence of chronic venous insufficiency in patients who experience leg edemaMethods:In a total of 1,226 patients (age 65.2± 15.0, 662 women) with leg swelling, specialized protocols for venous function tests were applied for diagnosis of CVI in a single center vascular ultrasound laboratory from Mar 2015 to Dec 2020 after exclusion of the presence of deep vein thrombosis. Duplex ultrasound scan on the greater and lesser saphenous veins was performed with patients erect or as upright as possible. Using a tilt table, patients’ position was flexibly changed. For the distal augmentation to assess for venous incompetence, we used the Hokanson®E20 Rapid Cuff Inflator. Pathologic reflux is defined by reversal of flow greater than 500 milliseconds in duration. The new CVI scoring system was calculated from logistic regression model. The VEIN-score were compared with cardiovascular risk scoring system established for other purposes.Results:607 patients (49.5%) were diagnosed with CVI. The final risk score ranged from 0 to 6 points and included six parameters: age ≥ 65 years, male sex, obesity (body mass index ≥ 25 kg/m2), hypertension, atrial fibrillation, and a history of myocardial infarction, which were derived from the results of logistic regression model (Figure A). The incidence of CVI gradually increased from 39% to 100%, as the score increased from 0 up to 6 points (Figure B). The new scoring system showed modest predictive value (C-index: 0.575, 95% CI: 0.544-0.606, cut-off value 3), higher than the CHA2DS2-VASc score and H2FPEF score.Conclusions:Old age, male sex, obesity, history of atrial fibrillation and myocardial infarction were significant risk factors for CVI. We propose VEIN-SCORE as a dedicated risk score model to predict chronic venous insufficiency in patients with leg swelling.

Circulation, Volume 150, Issue Suppl_1, Page A4142996-A4142996, November 12, 2024. Background:Secondary prevention after percutaneous coronary interventions (PCIs) is still challenging and lipoprotein(a) [Lp(a)] is believed to be a residual risk factor in this setting. However, the effect of Lp(a) in case of well-controlled low-density lipoprotein cholesterol (LDL-C) is still unclear. The interaction between Lp(a) and LDL-C has been studied in primary prevention but still needs to be investigated in secondary prevention.Hypothesis:Achieving adequate LDL-C control after PCI may reduce the cardiovascular (CV) risk associated with Lp(a).Methods:A retrospective study of consecutive patients who underwent PCI and reached their LDL-C target levels (

Circulation, Volume 150, Issue Suppl_1, Page A4144636-A4144636, November 12, 2024. Introduction:Mechanical Circulatory Support (MCS) is increasingly used in patients with cardiogenic shock (CS) or compromised hemodynamics during high-risk percutaneous coronary or structural interventions. Safe removal of large-bore MCS devices and closure of arteriotomy sites are crucial to prevent bleeding and vascular complications. Clot formation within intra-arterial sheaths post-MCS implantation poses a risk of thromboembolic complications, necessitating innovative approaches for safe removal.Case presentation:We present a 69-year-old male with a history of multivessel coronary artery disease (CAD), who was admitted with CS due to non-ST-segment elevation myocardial infarction (NSTEMI) requiring Impella CP device implantation. He later demonstrated hemodynamic stability with a heart rate ranging from 70 to 80 beats per minute and a mean arterial pressure (MAP) ranging from 75 to 80 mmHg, with the Impella set at power level 8 (P8). He underwent successful weaning from Impella support per protocol and was subsequently brought to the cardiac catheterization laboratory (CCL) for device explantation. The procedure began with the standard technique; however, upon inspection of the sheath following device removal, a sizable clot was visualized. To prevent embolization, we avoided standard retrograde wiring and instead, a Glide Advantage wire was threaded to the Impella sheath in an antegrade fashion via a contralateral access. A balloon was inflated within the sheath for dry field closure. Subsequently, the balloon and sheath were pulled together, extracting the clot in the process.Discussion:MCS utilization has risen, necessitating meticulous approaches to arterial access and device removal to mitigate bleeding and vascular complications. In our case, our primary concern revolved around the risk of embolization stemming from the sizable clot observed within the Impella sheath post-device removal when using the standard retrograde technique. This situation posed the potential for serious consequences, including acute limb ischemia, organ ischemia, or cerebrovascular accidents. Consequently, we needed to devise a novel technique for sheath explantation that would ensure safety and effectiveness. Our approach, employing the contralateral access and advancing the wire antegradely, provided a secure alternative, averting the severe consequences associated with clot embolization.